Leeds Teaching Hospitals NHS Trust (Leeds General Infirmary, St James’ University Hospital, Leeds)

Leeds General Infirmary,

Great George Street, Leeds, England, LS1 3EX

Tel: 0113 243 2799

St James’s University Hospital,

Beckett Street, Leeds, England, LS9 7TF

Tel: 0113 243 3144

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While the content of this guidance is fairly standard, the wording leaves a lot to be desired.

It quite clearly indicates how this Trust believes the “Obese Pregnant Woman” is a thing to be “managed”, and the tone of the language is divisive and confrontational. Big Birtha would be very interested to hear from anyone with first hand experience if the treatment received is equally so.

Some of the phrases which particularly rankle are:

“Maternal weight and height should be measured (self-reported weight is not acceptable)”.

Not acceptable? Who wrote this – Supernanny?! You are entitled to refuse to be weighed and self-report if you want to. It may not be advisable, as in the case of anaesthetic being required an accurate measure of weight is important, and they may find your refusal inconvenient, but let’s be clear, staff cannot force you onto a set of scales at your booking appointment, or into any other treatment for that matter.

The very first sentence of the Antenatal Care section reads;

“The risk assessment process commences at the booking appointment and continues throughout the care period.”

Interesting focus. A section on anenatal care that doesn’t start with information on antenatal care, but risk assessment?! While risk should be assessed and managed, obviously, what I read into this is that at Leeds, antenatal care for women with high BMI is basically risk assessment first, care comes second place.

It goes on to state that

“women who have a BMI of 30 kg/m2 and over require a glucose tolerance test”

Require? That should read should be offered. Later it goes on to say that

“Obesity strongly predisposes to diabetes…”

but if you look at the studies; Weiss (AJOG, 2004), for example, looked at more than 16,000 women and found that 9.5% of women with BMI 30+ had gestational diabetes, compared with 2.3% of women with a BMI under 30. I guess it depends on your perspective. 9.5% is significantly more than 2.3%, but in percentage terms it does leave more than 90% of women NOT developing gestational diabetes, which does not amount to a ‘strong disposition’ if you ask me.

Later it states;

“Obese patients often have very poor nutritional status with hypoalbuminaemia [a lack of protein in the blood] due to their poor diet”.

Without offering any evidence to substantiate this claim.

And then;

“All obese women should be encouraged to increase their level of exercise provided there are no medical contraindications.”

Personally, I find it the height of rudeness to advise women to increase their level of anything without actually asking what that level is first.

The guidance does at least score points with;

“scans in the third trimester, performed for whatever reason, may indicate that the baby is large for dates, increasing the chances of intervention. Ultrasound at this gestation is inaccurate in assessing large for dates babies (up to 25% error) and should not be relied upon when making decisions about time and mode of delivery. There is no evidence that induction of labour reduces the incidence of shoulder dystocia or increases the rate of vaginal delivery and intervention should be kept to a minimum.”

Unfortunately it then goes on to say;

“Any decision about induction should be made by the Consultant or a senior SpR”.

Err, no. Any decision about anything should be made by the woman herself. Medical professionals may advise or suggest courses of action, but decisions are for the woman and her partner.

It also states;

“Women with a BMI of 35 or above should not deliver at home or in water.”

but again, this is not based on anything more than opinion. All the studies on home birth and water birth focus on ‘low-risk’ pregnancies and so women with a high BMI are excluded from the results. This does not prove that home birth and water birth are unsafe for bigger women any more than it proves they are more safe for bigger women. Until there is reliable data, the jury is out. Plenty of bigger mums have had wonderful home and water births, Big Birtha included.

An amusing one:

“All hospital areas should ensure that obese woman, on admission are risk assessed and placed in an environment where the facilities ensure adequate circulation space and wide doorways.”

Placed? What, like a pot plant? And why the wide doorways? Because we might be too fat to waddle through a normal doorway? Baffled.

Lastly, there is this gem from their ultrasound policy:

“Obese women are a particularly difficult problem in terms of fetal surveillance.”

Not ‘present a problem’, or preferably ‘present a challenge’, but we are a problem, and a particularly difficult one at that. Great use of pejorative language again, Leeds. Well done.

In 2012, 1,792 women were subject to the policy. This equates to 18.17% of the women giving birth.

What you can expect:

If your BMI is between 25 and 30, you can expect to be given an information leaflet regarding weight management in pregnancy with information on the risks of developing complications.

If your BMI is between 30 and 35, you can expect the above, but you’ll also be told you ‘require’ a glucose tolerance test (GTT) at 26-28 weeks. If you have no additional risk factors you will be advised to book for ‘team based care’, but you can ask to continue with midwifery-led care, access to which is judged on an individual basis.

You can expect the usual ‘here’s all the things that are more likely to go wrong with your pregnancy because you’re fat’ conversation, and you’ll be assessed for risk of DVT (deep vein thrombosis) and considered for medication throughout your pregnancy if you have two or more other risk factors in addition to being overweight.

You will also be recommended an active management of the third stage of labour (injection to help detach and expel the placenta).

If your BMI is between 35 and 40, you can expect the above, but you’ll be classed as ‘high risk’ and you therefore ‘require referral’ for consultant care, and will be advised to deliver in hospital. However, the guidance does state that you may still be deemed appropriate for midwifery led care?

You’ll likely be expected to gain no more than 8kg during your pregnancy, and may even be advised to try to lose weight gradually.

If your BMI is between 40 and 45, you can expect the above, but you apparently ‘must’ receive consultant led care (no woman or baby-led care option, unfortunately) and ‘enhanced midwifery input’.

You will apparently ‘require’ an anaesthetic review, which might involve you being sent for an electrocardiogram, echocardiogram and chest x-ray in your third trimester?! You will be booked for a Glucose Tolerance Test appointment at both booking and at 26-28 weeks. You will also be offered additional scans at 28 and 34 weeks to check the baby is growing as it should.

You will be offered an ‘Enhanced Midwifery Care Pathway’ with a hospital midwife with ‘additional training in maternal obesity and weight management’ for ‘on going support and encouragement regarding weight management in pregnancy’ and for a bit of nagging on ‘the importance of lifestyle changes’ postnatally. You will be reweighed in each trimester, and referred to dieticians if there are concerns regarding your weight gain (or loss), if you gain or lose more than 4kg. Sounds like jolly good fun.

You’ll also receive a ‘manual handling assessment’ which tends to be a fairly patronising list of questions; do you need help to get off of a bed, go to the toilet, get in and out of a chair, when the person asking the questions has just seen you walk into the room perfectly normally.

As soon as you report to the hospital in labour they will want to insert a cannula for access to a vein in case you need an operative delivery later and access is difficult. You’ll also be advised to take heparin for 7 days after delivery to thin your blood as a precaution against DVT, even if you have no other risk factors for DVT, no matter how you deliver.

In Vitro Fertilisation

To be considered for IVF your BMI needs to be below 35, but getting funding from the NHS depends on the policy of your particular Primary Care Trust (PCT) as many restrict funding to those with a BMI under 30.

Policies current at February 2013

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